[Introduced January 21, 1998; referred to the
Committee on Banking and Insurance then Finance.]

A BILL to amend and reenact section eight, article sixteen,
chapter five of the code of West Virginia, one thousand nine
hundred thirty-one, as amended; to amend and reenact section
twenty-one, article one, chapter thirty-three of said code;
to amend and reenact section three-i, article sixteen of
said chapter; to amend and reenact section seven-e, article
twenty-four of said chapter; to amend and reenact section
eight-d, article twenty-five of said chapter; to amend and
reenact section eight-d, article twenty-five-a of said
chapter; to amend article one of said chapter by adding
thereto a new section, designated section twenty-two; and to
amend article fifteen of said chapter by adding thereto a
new section, designated section twenty-one, all relating to
deleting the past deadline date for the public employees
insurance agency to provide cash incentive plans; and providing definitions relative to services provided during
emergencies.

Be it enacted by the Legislature of West Virginia:
That section eight, article sixteen, chapter five of the
code of West Virginia, one thousand nine hundred thirty-one, as
amended, be amended and reenacted; that section twenty-one,
article one, chapter thirty-three of said code be amended and
reenacted; that section three-i, article sixteen of said chapter
be amended and reenacted; that section seven-e, article
twenty-four of said chapter be amended and reenacted; that
section eight-d, article twenty-five of said chapter be amended
and reenacted; that section eight-d, article twenty-five-a of
said chapter thirty-three be amended and reenacted; that article
one, chapter thirty-three of said code be amended by adding
thereto a new section, designated section twenty-two; and that
article fifteen of chapter thirty-three be amended by adding
thereto a new section, designated section twenty-one, all to read
as follows:

CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR,

SECRETARY OF STATE AND ATTORNEY GENERAL; BOARD

OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS,

OFFICES, PROGRAMS, ETC.

ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.§5-16-8. Conditions of insurance program.The insurance plans herein provided for shall be designed by
the public employees insurance agency:
(1) To provide a reasonable relationship between the
hospital, surgical, medical and prescription drug benefits to be
included and the expected reasonable and customary hospital,
surgical, medical and prescription drug expenses as established
by the director to be incurred by the affected employee, his or
her spouse and his or her dependents. The establishment of
reasonable and customary expenses by the public employees
insurance agency pursuant to the preceding sentence is not
subject to the state administrative procedures act in chapter
twenty-nine-a of this code.
(2) To include reasonable controls which may include
deductible and coinsurance provisions applicable to some or all
of the benefits, and shall include other provisions, including,
but not limited to, copayments, preadmission certification, case
management programs and preferred provider arrangements.
(3) To prevent unnecessary utilization of the various
hospital, surgical, medical and prescription drug services
available.
(4) To provide reasonable assurance of stability in future
years for the plans.
(5) To provide major medical insurance for said employees.
(6) To provide certain group life and accidental death
insurance for the employees covered under this article.
(7) To include provisions for the coordination of benefits
payable by the terms of such plans with the benefits to which
such employee, or his or her spouse or his or her dependents may
be entitled by the provisions of any other group hospital,
surgical, medical, major medical, or prescription drug insurance
or any combination thereof.
(8) To provide a cash incentive plan for employees, spouses
and dependents by the thirty-first day of December, one thousand
nine hundred eighty-eight, to increase utilization of, and to
encourage the use of, lower cost alternative health care
facilities, health care providers and generic drugs. Such plan
shall be reviewed annually by the director and the advisory
board.
(9) To provide "wellness" programs and activities which will
include, but not be limited to, benefit plan incentives to
discourage tobacco, alcohol and chemical abuse and an educational
program to encourage proper diet and exercise. In establishing
"wellness" programs, the division of vocational rehabilitation
shall cooperate with the public employees insurance agency in
establishing statewide wellness programs and with such division of vocational rehabilitation to contact county boards of
education for the use of facilities, equipment or any service
related to such purpose, at the request of the director, under
the authority hereby granted to contract therefor. Boards of
education shall be limited to charging only the cost of
janitorial service and increased utilities for the use of the
gymnasium and related equipment. The cost of the exercise
program shall be paid by county boards of education, the public
employees insurance agency, or participating employees, their
spouses or dependents. All exercise programs shall be made
available to all employees, their spouses or dependents and shall
not be limited to employees of county boards of education.
(10) To provide a program, to be administered by the
director, for a patient audit plan with reimbursement up to a
maximum of one thousand dollars annually, to employees for
discovery of health care provider or hospital overcharges when
the affected employee brings such overcharge to the attention of
the plan. The hospital or health care provider shall certify to
the director that it has provided, prior to or simultaneously
with the submission of the statement of charges for payments, an
itemized statement of the charges to the employee participant for
which payment is requested of the plan.
(11) To require that all employers give written notice to each covered employee prior to institution of any changes in
benefits to employees, and to include appropriate penalty for any
employer not providing the required information to any employee.
(12) To provide coverage for emergency services under
offered plans. For the purposes of this subsection, "emergency
services" means services provided in or by a hospital emergency
facility or the private office of a dentist to evaluate and treat
a medical condition manifesting itself by the sudden, and at the
time, unexpected onset of symptoms that require immediate medical
attention and that failure to provide medical attention would
result in serious impairment to bodily function, serious
dysfunction to any bodily organ or part, or would place the
person's health in jeopardy.the following definitions shall
apply:(A) "Emergency services" are:
(i) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(ii) An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(iii) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital, medical or dental corporation or any other third-party payor, or
any representative thereof, has authorized, directed, referred or
otherwise required or permitted the insured to use or obtain;
(B) "Emergency Medical Condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in placing the health of the individual, or, with respect
to a pregnant woman, the health of the woman or her unborn child
in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part.

CHAPTER 33. INSURANCE.

ARTICLE 1. DEFINITIONS.

§33-1-21. Emergency services.
Emergency services are: those services provided in or by a
hospital emergency facility or the private office of a dentist to
evaluate and treat a medical condition manifesting itself by the
sudden, and at the time, unexpected onset of symptoms that
require immediate medical attention and that failure to provide
medical attention would result in serious impairment to bodily
function, serious dysfunction to any bodily organ or part, or
would place the person's health in jeopardy.(a) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(b) An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(c) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital,
medical or dental corporation or any other third-party payor, or
any representative thereof, has authorized, directed, referred or
otherwise required or permitted the insured to use or obtain.§33-1-22. Emergency medical condition."Emergency Medical Condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in placing the health of the individual, or, with respect
to a pregnant woman, the health of the woman or her unborn child,
in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part.

ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.

§33-15-21. Coverage of emergency services.(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall provide as benefits to all
subscribers and members coverage for emergency services. A
policy, provision, contract, plan or agreement may apply to
emergency services the same deductibles, coinsurance and other
limitations as apply to other covered services: Provided, That
preauthorization or recertification shall not be required.
(b) For purposes of this article, the following definitions
shall apply:
(1) "Emergency services" are:
(A) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(B An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(C) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital,
medical or dental corporation or any other third-party payor, or
any representative thereof, has authorized, directed, referred or
otherwise required or permitted the insured to use or obtain.

ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.

§33-16-3i. Coverage of emergency services.(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall on and after the first day
of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services: Provided,
That preauthorization or precertification shall not be required.(b) For purposes of this article, the following definitions
shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(b) An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(c) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital,
medical or dental corporation or any other third-party payor, or
any representative thereof, has authorized, directed, referred or otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in placing the health of the individual, or, with respect
to a pregnant woman, the health of the woman or her unborn child
in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part.ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND HEALTH SERVICE CORPORATIONS.
§33-24-7e. Coverage of emergency services.(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall on and after the first day
of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services: Provided,
That preauthorization or recertification shall not be required.(b) For purposes of this article, the following definitions
shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(b) An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(c) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital,
medical or dental corporation or any other third-party payor, or
any representative thereof, has authorized, directed, referred or
otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in placing the health of the individual, or, with respect
to a pregnant woman, the health of the woman or her unborn child
in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part.

ARTICLE 25. HEALTH CARE CORPORATIONS.

§33-25-8d. Coverage of emergency services.(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall, on and after the first
day of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services: Provided,
That preauthorization or precertification shall not be required.(b) For purposes of this article, the following definitions
shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(b) An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(c) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital,
medical or dental corporation or any other third-party payor, or any representative thereof, has authorized, directed, referred or
otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in placing the health of the individual, or, with respect
to a pregnant woman, the health of the woman or her unborn child
in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part.

ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.

§33-25A-8d. Coverage of emergency services.(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall, on and after the first
day of July, one thousand nine hundred ninety-six, provide as
benefits to all subscribers and members coverage for emergency
services. A policy, provision, contract, plan or agreement may
apply to emergency services the same deductibles, coinsurance and
other limitations as apply to other covered services: Provided,
That preauthorization or precertification shall not be required.(b) For purposes of this article, the following definitions shall apply:
(1) "Emergency services" are:
(a) Those services which are needed to evaluate and
stabilize an emergency medical condition;
(b) An initial medical screening examination and any
immediately necessary stabilizing treatment as required by the
Emergency Medical Treatment and Active Labor Act, 42 U.S.C.
§1395dd; or
(c) Any emergency service which any insurer, health
maintenance organization, health care corporation, hospital,
medical or dental corporation or any other third-party payor, or
any representative thereof, has authorized, directed, referred or
otherwise required or permitted the insured to use or obtain.
(2) "Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson who
possesses an average knowledge of health and medicine could
reasonably expect the absence of immediate medical attention to
result in placing the health of the individual, or, with respect
to a pregnant woman, the health of the woman or her unborn child
in serious jeopardy, serious impairment to bodily functions or
serious dysfunction of any bodily organ or part.

NOTE: The purpose of this bill is to change the definition
of emergency services so as to be consistent with federal
practice requirements for emergency room physicians and to also
define "emergency medical condition." The definitions apply to
the public employees insurance agency, individual and group
accident and sickness insurance policies, hospital, medical and
dental corporations, health care corporations and health
maintenance organizations.

Strike-throughs indicate language that would be stricken
from the present law, and underscoring indicates new language
that would be added.

§§33-1-22 and 33-15-21 are new; therefore, strike-throughs
and underscoring have been omitted.